One of my most common requests at work is for people to think clearly and consistently, and follow this up with a definite decision. But when I write on this blog, I’m often calling for people to think not in terms of ‘bright lines’, but messy nuance.
I’ve been wondering about this possible inconsistency recently, and then a story has come out that has put things into focus for me. The simple, and slightly trite answer, is that we can think perfectly clearly and openly, with consistent principles, but sometimes these come into conflict with each other, or meet complex problems were a perfect – or even neat – solution is impossible.
The story that prompted this was the potential ‘rationing’ of treatments within the NHS, based on people’s weight and/or whether they smoke.
I was originally going to write something making the point that there are straightforward, but painful, choices for the public sector to do in the next few years, as predicted ‘demand’ increases for a range of reasons (mostly demographic) while funding from central government decreases – to zero, in the case of local authorities. When systems are having to generate savings of 50% or more, talk of efficiencies is not just irrelevant, but potentially misleading and unhelpful. Although the NHS hasn't been cut in the way that local authorities have, the reason there is increasing interest in tying health and social care together is that they are inextricably linked – not just for the patient or service user, but in terms of costs. ‘Savings’ in social care, if not planned and delivered in partnership with the NHS, will simply lead to the balloon bulging elsewhere, in hospital admissions and length of stays, for example.
How are the choices ‘straightforward’ then, if funding is falling, demand is rising and the costs are shared between a whole range of organisations? Well, the decision boils down to the fact that if the current spectrum of services are to be delivered, even if in a more ‘efficient’ way, there won’t be the budget to offer them to everyone – so they will be more ‘rationed’ in the terms of the article about NHS treatments.
That is, organisations will do less for some people, but maintain a stronger (or cheaper) service for others. This does indeed undermine the principles of the NHS, but it’s the way local authorities and other elements of government have always operated, using means testing and targeted support, even where it’s not immediately apparent.
The only real alternative is to do less for everyone. My gut feeling is that this would require a change in our attitude to the NHS, which can sometimes be seen as a universal service as delivering support not only to everyone, but for everything. (Of course there is one alternative, which is to change the funding envelope.)
But what about my calls for ‘irrational policy’ and ‘compromise’? The reality is that while you can accept a clear principle, there are no simple answers about what that means in practice. What do you stop doing? Why? Who do you target? Why? How? What are the consequences?
And that’s where the thinking is sometimes muddled, or there’s a reluctance to take the decision between those two very clear options. There’s reluctance to draw a line because it’s seen as too definite. Some people might say that it’s too difficult, or inappropriate, to draw lines like this. We’re on a slippery slope by making a dent in universalism.
But universalism is drawing a line too. It’s just that the line is either at one extreme or another, and is therefore can appear very simple. It’s this simplicity that brings together self-styled defenders of the NHS – like Laurie Penny – and those who would prefer a market-based solution – like Chris Snowdon – in attacking the decision of the Vale of York CCG. They’re at one extreme or another, but highlighting the inconsistency.
The thing is (and I should acknowledge this is where the opposition of people like Chris to the NHS is perfectly coherent*): with a fixed budget there is always a trade-off between those same ideas of doing less for everyone, or targeting particular groups.
The NHS is a classic example of this. We need NICE and CCGs to make decisions about what treatments are available, because they can’t offer everything. And with a fixed budget that principle has to apply even if those decisions apply equally to all users of the system. (And the budget is inevitably fixed to some extent; it is not infinite.)
There are good reasons to maintain that absolute principle of universalism in the NHS, but we mustn’t be under any illusion: this equally requires the ‘rationing’ of services through CCGs and NICE. And those ‘rationing’ decisions can’t be straightforward.
This all sounds a bit academic, and perhaps even a case of semantics. But let’s see how it can work in practice, and how point about complexity is exactly how we go through our lives – not just for better or worse, but for better.
David Seedhouse, Professor of ‘values-based practice’ at the University of Worcester, wrote in the Guardian that just as hospital sites have gone ‘smoke free’, they should go ‘meat free’ too, as both meat and tobacco are carcinogens.
By taking this consistent position, it’s suggested, we can avoid ‘stunning inconsistencies’ such as this form of Orwellian ‘doublethink’:
“Either it’s OK to allow free choice or it’s OK to prevent ‘unhealthy behaviours’, but you can’t have it both ways … If you don’t ban meat, then you can’t ban smoking.”
Perhaps unsurprisingly, Chris Snowdon swiftly congratulated this reasoning. (Although it wasn’t planned, it’s no coincidence we both chose to write about these two articles together, from quite different perspectives.)
In fact, the decision isn’t simply a choice between ‘free choice’ and preventing ‘unhealthy behaviours’.
First, on a technical point, health isn’t a binary. Substances and behaviours – and particularly patterns of behaviour – can’t solely be described as ‘healthy’ or ‘unhealthy’. The category of carcinogen depends on a causal link between the substance and cancer, not the probability or level of risk. That is, someone whose published academic work focuses on health promotion makes exactly the mistake that has frustrated many who are interested in the new alcohol guidelines.
Meat might have some similar attributes to tobacco or smoking, but it’s not the same. And that’s before we even get started on the fact that most people, if they had to choose one category, would probably classify meat as a food (a group of things essential for life), rather than as a carcinogen, while tobacco would be an intoxicant (something of a luxury, if perhaps essential for a functioning society).
What’s more, freedom isn’t a neat binary of ‘free’ and ‘unfree’, as politics, philosophy, theology, psychology, sociology, neuroscience and any other area of human study will tell you. False consciousness, structure and agency, predestination – all these concepts and more are attempts to cut this Gordian knot.
But we know all this intuitively already. That’s why the reaction I saw this article receive on Facebook and Twitter was ridicule, without even having to enter into an extended period of intellectual reflection. We see the world not in black and white, but in infinite shades of colour.
Of course Seedhouse would respond that it’s revealing that those Twitter and Facebook comments didn’t involve much reflection:
“So long as we see the world in disconnected chunks, we can avoid serious thought, and preserve the status quo. We need more opportunity to think deeply for ourselves.”
In fact, he’s the one who is thinking in a superficial, simplistic way. He writes that “Illogical beliefs appear compatible if their true connections are disguised.” But the point is that things that are connected are not identical. It’s easy to make a connection; more difficult to specify precisely what the nature of that connection is. I’ll say again, meat and smoking are not the same.
The point is that all issues are on a slope, which means that libertarians fear the ‘slippery slope’ and others like David Seedhouse want everything to slide down to the bottom as quickly as possible. But the fact is that not all slopes are or should be slippery. It’s more likely the best solution is somewhere along the slope rather than at the top or the bottom. If you find yourself at either end you’ll soon discover there’s another slope available. Personally I think individuals and society are better served having a bit of stability rather than constantly sliding up or down the endless slopes that exist in the world.
But let’s bring the discussion back to me, this blog and my personal frustrations.
What all this means is that even if the principles are clear, and a decision is taken, we still have to face a messy reality. So let’s not be afraid of making decisions and drawing lines, but equally let’s not imagine that act of drawing a line will simplify and make everything follow. It won’t make things simple; it will only make things transparent. But I’d say messy clarity is better than messy confusion.
*I have much more to say about this, and how insurance and purchasing schemes don’t really avoid this trade-off, but I’ll save that for another day.